Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you continue hydroxychloroquine in lupus patients who develop cardiomyopathy?
The short answer is yes, in that most lupus patients with cardiomyopathy do not have hydroxychloroquine drug induced cardiac injury. That is to say most of these patients either have ischemic cardiomyopathy or non-drug NICM. With that said, antimalarials can produce adverse effects both on the cardi...
Would you re-challenge patients who have had a TNF-associated paradoxical adverse event (such as inflammatory bowel disease) with a different TNF inhibitor?
I honestly have not heard of IBD as a paradoxical event with TNF inhibitors (unless possibly in a patient with underlying IBD that was not being treated adequately with etanercept rather than a monoclonal anti-TNF antibody). On the other hand, I have seen paradoxical psoriasis with TNF inhibitor use...
Is it okay to use COX-2 selective NSAIDs in patients with IBD-associated arthritis when the IBD is in remission?
I do not feel comfortable prescribing COX-2 NSAIDS to patients with IBD in remission. If I have such a patient and an NSAID is the major therapeutic option, I will reach out to the treating gastroenterologist for an opinion on whether this is advisable.
Should patients be screened for hepatitis B/C prior to starting a conventional synthetic DMARD such as methotrexate?
If you are even thinking about it, YES!!!!AASLD suggests HBV screening when contemplating immunosuppression with HBsAg, anti-HBcore, and anti-HBs for immunization status (separate issue). HCV-Ab should be done at the same time as I have advocated for many years, but now, the practice is catching up ...
How do you manage patients who are Hepatitis B core antibody positive/surface antigen negative and starting a biologic DMARD (other than rituximab)?
According to the 2015 American College of Rheumatology Guidelines, a patient with natural immunity to Hepatitis B (Core & Surface Antibody-positive; Antigen-negative, normal liver function tests) can be treated as any other patient. However, monitoring of viral load is recommended "regularly" at 6-1...
Do you regularly do bone density testing to screen for osteoporosis in men with rheumatoid arthritis without any other risk factors?
An important comorbidity in RA is fragility fractures. These patients are at higher risk of OP because of increased pro-inflammatory cytokines and glucocorticoid treatment. OP screening strategies are both feasible and effective in RA patients and recommended by most specialty organizations. Both me...
In which osteoporosis patients would you consider starting with anabolic therapy over antiresorptive therapy?
Anabolic therapies including teriparatide (PTH-analog), abaloparatide (PTHrP-analog), and romosozumab (anti-sclerostin) are all indicated for patients with osteoporosis and high fracture risk. Although denosumab (anti-RANKL) is an antiresorptive agent, it also leads to significant bone gain similar ...
When treating patients with low bone mineral density, when/how do you monitor bone turnover markers (NTX, CTX, etc)?
It is a bit difficult to answer this question without more information. If you are monitoring a patient during a drug holiday, I would order a CTX-1 and PINP when discontinuing the bisphosphonate and then again after one year. If the levels have increased over 50% from the year before that would tri...
What is your treatment algorithm for RS3PE?
RS3PE is an interesting condition. In my experience, it typically presents older individuals aged 70 and beyond. Men are more commonly affected. The upper extremities are generally involved unilaterally or bilaterally. In cases of unilateral involvement, one should consider other diagnoses as well, ...
What is the role of nintedanib in the treatment of SSc-ILD?
Nintedanib has shown to be effective for treating patients with ILD associated with systemic sclerosis, as the annual rate of decline in FVC was lower with nintedanib than with placebo (SENSCIS trial). However, the majority of patients treated with nintedanib in this trial were also on MMF therapy. ...